GW1-2021-02313_Well Construction - GW1_20210709

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WELL CONS W:+ l u m W-1 + For Internal Use Only:
1.Well Contractor Information: „
Ronald G. Cannad r tt 9 4O IA.W TER7.ANES
Wci1 Contractor Name TO D6S P[tON
212 -A t.onproces Og fin. 35 n. L,i,o,;�,�
lrlWTM i Se n. n.
NC Well ConinictorCcnificatlan Number Q t 15,OUTER CASING froratniti-lased wefts OR ktNBR !a cable
Cannady Brothers Well DdRing, Inc. FR,OrM TO DIAMETER TRiCINJSS AtATEtttAt
Company Name
t✓ n. () n I- tn.
C)i O 16.INNER G ORT LIBING fecotheirrhall clowd4noftV
2.Well Construction Permit i1; J / FROM I TO I DIAMETER I THICKIIESS IMATERIAL
Lis)all applicable still Construction permits(Le.UIC.Coun(r.State.Parlance.ere.) n. n: In.
3.Well Use(cheek well use): n• n-
[A46cultuml
Supply Well: 17.SCREEN
Muni ipaU)*ubiic FaaM n res as ILmAA� in,ER I t or tzE rtuCtt ass MAJt•hcmtal(Hcating/Cooling Supply) Welial Water Supply(single) n.striaUCommercialSAw l.. enclential Water Supply(shared) ]&GROUT
mg,
#ROM TO t TERIAL ta4tPLACEAtF3tT3i OD&AMOUNT
Non 1Yatcr Supply Well: n. v n. 074•L 1
Monitoring Recovery n.. st..
--- Injection well:
n. A.
Aquifer Recharge OGroundwalcr Remediation 19.SANDIGRAVEl.PACK f piollable .
Aquifer Storage and Recovery [3Solinity Barrier FROM TO I ArAnItIAL EMPt.ACEMEN"T METHOD
Aquifer Test OStormwater Drainage a O n S n. �dt �� I f� �1
Exjiarimcntal Technology OSubsidence Control R. ft.
Geothermal(Closed Loop) OTrmccr 20.DRR 1.l 4G LOGt ethi Will oiaid'sbeets it riecease
Geothermal Hcati ooligg Return) 001her(explain under 021 Remarks FnoAtI TO DEWRIVIrION fechir.hardn saatrork VIM rMin III%ttc
n. n. -�� p
4.Date Well(s)Completed: Well 1DIf n. n.
5n.Well Location:
n, n
Face itylow"cr Name Facility 10H(ifapplicable) n n.
f7` � wG�D IJG
Physical Addrass,City,and Zip
_V 3 a ay 21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutestseconds or decimal degrees:
(if well field.one InViongis sliflichou 22 cation.
t�k 6z N 'f u ' 4' 7 k_53fo W /
(M �:��'►-n .�
6.ls(ore)the well(s) ermanent or 131r'emporary SignaturcofCcrufted Well Contractor is
ti9 slgn(ag this f-1.1 hereby ecrto that the uvil(s)um(urre)Constructed lit accordance
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If ills is a mpair,fill out knoum civil construction Information and=plain the noturo`ofrhe roP)'oJlhls recotxl hers been protidrd hi the url/e1tmr.
relmir under(121 minarls section or on the hack of yids furat.
23.Site diagram or additional well details:
8.ror Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only)G W-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SSUOMITTAL JNU.._ oN_J
9.Total well depth below land surface: (11•) 24a. Far All ftl, Submit this form within 30 days of completion of well
1,ar nudtiple ovllc list all depihs ifd(jferent(¢rample-T rt pn''ond 2Gltti)1 construction to the following:
10.Static water level below top of casing: / (R) Division of Water Resources,Information Processing Unit,
Tuater leirl is ahmv casfug,are"+' ` 1617 Mail Service;Center,Raleigh,NC 27699-1617
11.Borehole diameter: `5'r (in.) 24b.For inicetion Welts: In addition to sending the form to die address in 24a
Rota above,also submit one copy of this form within 30 days of completion of weal
l2.Well construction Cable, method, construction to the following:
(i.e.au�n:r,rotary,Cable,direct push,etc.}
FOR WATER SUPPLY WELLS ONLY: Division of Water Rcsourctts,Underground Injection Control Program,
1636 Mail Service,Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test:_ //�✓ 24c.For!A ter Sunnty 8c Iniettiot}Wells: In addition to sending the form to
the addmss(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: I i) completion of well construction to the county health department of the county
where constructed.
Fortn Gw-I North Carolina Department of Environmental Quality-Division of water ittsoumcs Revised 2.22.2016